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Age-related causes of emergency department visits after pediatric adenotonsillectomy at a tertiary pediatric referral center
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109668
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Age-related causes of emergency department visits after pediatric adenotonsillectomy at a tertiary pediatric referral center
T
Nathan R. Lindquista, Zipei Fenga, Ankita Patrob, Shraddha S. Mukerjic,∗ a
Department of Otolaryngology, Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA Vanderbilt Department of Otolaryngology, Nashville, TN, USA c Texas Children's Hospital, Department of Otolaryngology, Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Tonsillectomy Adenotonsillectomy Young Complications Age Revisits
Introduction: The complications of tonsillectomy and adenoidectomy (T&A) are well-described and include bleeding, dehydration, nausea, respiratory complications, and pain. After the immediate postoperative phase, the overall 30-day emergency department (ED) return rate is as high as 13.3%. However, few studies have examined the types and rates of late post-operative complications for children undergoing T&A stratified base on patient age. Herein, we aim to better characterize ED return visits for children of all ages, with special attention to those patients under three years of age. Methods: This is a retrospective case series at a tertiary academic pediatric medical center. All patients 18 years of age or younger who underwent T&A over eighteen months were included. Data including ED return diagnosis, post-operative day of presentation, and need for surgical intervention was recorded for patients who presented to the ED within 30 days of their original surgery. Results: 5,225 patients were identified, with an overall late complication rate of 12.8%. There was no difference in the 30-day ED readmission rate for children under the age of three, although children under the age of two were more likely to present to the ED. There was a significantly higher risk of dehydration for children under the age of four years, and a significantly higher bleeding risk and need for reoperation for control of post-tonsillectomy hemorrhage (PTH) for children over the age of six. Conclusions: The overall ED visit rate in this study is 12.8%, with no difference based on age. Patients younger than three years of age are more likely to return to ED for dehydration, while bleeding and need for control of oropharyngeal hemorrhage is more common in older children. Knowledge of the age-related late complications of T&A may direct appropriate anticipatory peri-operative counseling of risks and return precautions.
1. Introduction Tonsillectomy and adenoidectomy (T&A) is the second most performed ambulatory surgery for children in the United States [1,2]. The post-operative complications of tonsillectomy are well-described and include primary and secondary bleeding, as well as nausea, emesis, pain, dehydration, and respiratory issues such as post-obstructive pulmonary edema [3]. Late complication after T&A is defined as any complication occurring 24–48 h after surgery. Due to cited increased complications in children under the age of three, in children with other risk factors such as craniofacial disorders or Trisomy 21, and in children with severe sleep apnea, the recently updated American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS) Clinical Practice Guidelines for Tonsillectomy in Children recommends overnight inpatient monitoring for these children [4]. Multiple studies ∗
support statistically significant higher airway or respiratory complication rates for children age three and under, within the first 24 h after surgery [5,6]. Although post-T&A admission rates vary across tertiarycare centers, we routinely admit children under 3 years of age for postoperative 23-h observation [7]. The most common late complications include secondary post-tonsillectomy hemorrhage (PTH) or dehydration [8]. A retrospective review of the Pediatric Health Information System Database calculated a median 30-day return rate of 7.8%, with individual institution rates varying from 3.0% to 12.6% [9]. However, a recent study by Curtis et al. estimates an overall emergency department (ED) return rate at 13.3% for late post-operative complications for all children who underwent T&A at their institution [10]. These authors estimate that these visits make the global cost of T&A approximately 10% more costly than the perioperative costs, and suggest improved pain regimens and
Corresponding author. Texas Children's Hospital - West Campus, 18200 Katy Freeway, Suite 540, Houston, TX, 77094, United States. E-mail address: [email protected] (S.S. Mukerji).
https://doi.org/10.1016/j.ijporl.2019.109668 Received 1 May 2019; Received in revised form 20 August 2019; Accepted 31 August 2019 Available online 04 September 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109668
N.R. Lindquist, et al.
effective patient-communication as tools to decrease ED return visits. The objective of the study is to characterize patients that returned to the ED within the first 30 days of their T&A with regards to age and reason for presentation. We aim to augment the information obtained in prior studies by further analyzing age-specific reasons for ED visits after T&A surgery in a large study population. We believe that this information will serve as an improved guide to the patient's families regarding their expectations of perioperative recovery.
Table 2 Total complication rates.
2. Materials and methods Our retrospective chart review study was approved by the Institutional Review Board. An electronic medical record query was performed for all children under the age of 18 years who underwent T& A at our institution from January 3, 2017 to July 3, 2018. The inclusion criteria for this group was broad. All patients undergoing T&A were included, even if they underwent additional procedures. In addition, we did not exclude children with comorbidities or additional diagnoses. Data including age, gender, date of admission, date of surgery, American Society of Anesthesiologists (ASA) Score, and length of surgery were collected. Information including return diagnosis, post-operative day of presentation, and need for surgical intervention was obtained for patients who presented to the ED within 30 days of their original surgery. Patient reasons for ED visit or hospital readmission were sorted categorically into dehydration, bleeding, pain, nausea/ emesis, respiratory problems, fever, and others. For those patients requiring additional surgical intervention, Current Procedural Terminology (CPT) codes were collected and utilized in calculating PTH rates. At our institution, children under the age of three and those with moderate to severe OSA are routinely observed overnight following T& A. The standardized T&A pain regimen includes scheduled ibuprofen every 6 h with acetaminophen given as needed for breakthrough pain. In addition, a post-operative oral steroid dose is offered, on an as needed basis, between post-operative days four to seven. Statistical analysis was performed using Prism and Microsoft Excel. Unpaired T test, linear regression and ANOVA were used where appropriate. Statistical significance was established at p < 0.05.
5225 (100%) 2478 (47.5%)
251 (4.8%) 260 (5.0%) 31 (0.6%) 30 (0.6%) 16 (0.3%) 64 (1.2%) 15 (0.3%) 667 (12.8)
Our study showed significant age-related differences in the primary indication for return ED visits after T&A surgery. These results are similar to a previous large-scale retrospective cohort studies of the Pediatric Health Information System Database [9]. We noted that children under the age of four years had a significantly higher risk of dehydration, this was most significant in children under 2 years of age. We believe that this may be due to poorer pain control related to resistance to taking oral pain medications, lower physiologic reserve for fluid losses, and a lower parental threshold for ED presentation in younger children. Post-tonsillectomy bleeding and operating room return rate for control of PTH was increased for children over the age of six years [9,11,12]. This is similar to other studies that show increased rates of PTH for older children. Many older children undergo T&A for recurrent streptococcal tonsillitis which is known to be associated with increased incidence of PTH [12]. Our study evaluated a large cohort of patients undergoing T&A within an 18-month period, including nearly 10% of patients under the age of three years. Among all 5,199 patients, the post-operative 30-day ED readmission rate was 12.8%. This figure is within the range of 6.3%–13.3%, as reported in the literature [8–10]. Interestingly, there was no statistically significant difference in overall rates between the groups of children older or younger than three years. Our results also showed that children under 3 years of age have a higher ASA score. The ASA classification assumes that age is unrelated to physical status, although in practice the extremely young and elderly are far less tolerable of anesthetics as compared to normal, healthy young adults [13]. Either consciously or subconsciously, the ASA
Table 1 Patient characteristics.
Patient number Female Age Age < 3 0-2 2-3 Age > 3 3-4 4-5 5-6 6-7 7-8 8-18
Dehydration Bleeding Pain Emesis Respiratory Problems Other Fever Overall complication rate
4. Discussion
Included in the study cohort were 5,225 patients under the age of 18 whom underwent T&A at our institution between the specified dates (Table 1). The median age for this group was six years, and 48% of all patients were female. Overall rate of complication was 12.8% based on 30-day return to the Emergency Center, with dehydration and bleeding the most common primary indications for return visits (Table 2). Patients were divided into two groups based on age: less than 3 years and more than or equal to 3 years. Patients below the age of three
Number (%)
5225 (100%)
accounted for 10% of the study population. Of those patients, 39% of patients were female. Pre-operative risk stratification demonstrated a significantly higher ASA score for children under the age of 3 (Fig. 1A, p < 0.0001). No significant difference was demonstrated in operative time between the two groups. (Fig. 1B, p = 0.8). Post-operative 30-day Emergency Department (ED) readmission rate was 12.8% overall, with no statistically significant difference between the two groups. (Fig. 1D, p = 0.9). However, categorization of patients based on intervals of one year under the age of eight demonstrated a higher rate of 30-day returns to the ED in patients under age of 2 (Fig. 3A, p < 0.03) (see Fig. 2). Further analysis based on individual primary diagnoses for ED visits indicated a significantly higher risk of dehydration for children under the age of four years (Fig. 3B, p < 0.03). The bleeding risk and OR return rate for control of PTH was increased for children over age of six years compared to less than 6 years (Fig. 3C, p < 0.0001). We did not observe a statistically significant difference in ED presentation for postoperative pain or emesis across the study cohort. (Fig. 3D and E, p > 0.05). No significant difference was observed in rate of respiratory problems, fever and other causes of ED visits (Fig. 3F,G,3H, p > 0.05). In addition to the discretely defined categories, other causes of presentation included asthma, cough, epistaxis, gastroenteritis and motor vehicle collision.
3. Results
Characteristics
Primary Complications (All Ages)
515 (10%) 78 (1.5%) 437 (8.3%) 4703 (90%) 645 (12.3%) 695 (13.3%) 701 (13.4%) 650 (12.4%) 477 (9.1%) 1542 (29.5%)
2
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109668
N.R. Lindquist, et al.
Fig. 1. General characteristics of the study population 1A) Increased ASA score in children under 3 years of age. 1B) Surgery time between the two groups. 1C) Increased length of hospitalization in children under 3 years of age. 1D) Percentage of patients returning to ED.
approximately 10% higher than the perioperative cost across all age groups based on an ED visit. Interventions to decrease the dehydration rate, improve pain control and lower the risk of post-tonsillectomy hemorrhage may include perioperative parent and patient counseling, as well as different techniques including intracapsular tonsillectomy (IT). There is strong evidence mounting for IT for sleep-disordered breathing, including more expedient resolution of pain, return to normal diet & activity, lower analgesic requirement, and a lower rate of secondary PTH [14–16]. Strengths of our study include a large study cohort and significant information on ED return rates following T&A categorized by age and reasons for ED visits. We acknowledge a few weaknesses as well. Our study was a retrospective in design and therefore has its inherent limitations. We completed this review in one hospital system, and therefore, our results may not be generalizable to hospital systems of differing sizes or regions. In addition, the patient population at a tertiary referral center is markedly different from those of community otolaryngology practices. It is likely that a higher proportion of medicallycomplex and/or younger children undergo tonsillectomy at our institution. However, our hospital system has several community-based health centers that usually attract otherwise healthy children needing T &A surgery so our results should be generalizable to a large extent. With regards to return visits, it is possible that patients presented to other institutions for post-operative issues due to locality or preference and are thus underrepresented in our follow-up cohort. We also did not evaluate the effect of existing co-morbid conditions to ED return visits.
Fig. 2. Frequency of ED visits by diagnosis for the two study groups. Statistical testing was performed using unpaired parametric test, significance was established at p < 0.05. * = p < 0.05, ** = p < 0.01. DH (dehydration), BL (Bleeding), PA (Pain), EM (Emesis), RD (Respiratory distress), OT (Other), FE (Fever).
grading of increasingly younger children undergoing T&A may be biased by these assumptions. Recently, Curtis et al. examined the cost and etiologies for postoperative ED visits in patients undergoing T&A of all ages [10]. In their study, 13.3% of patients (n = 437) presented to the ED at a mean of 4.4 post-operative days and were included in the cohort. Similar to our data, 4.2% presented with dehydration, 3.3% for post-tonsillectomy hemorrhage, 2.0% for uncontrolled pain, 1.3% for fever, 1.0% for vomiting/nausea/GI discomfort, 0.7% for respiratory issues, and 1.2% for other causes. The subgroups in their analysis with the highest mean cost of readmission were those patients with respiratory complications ($2855), hemorrhage ($1502), and dehydration ($1372), while uncontrolled pain was the least expensive ($781). Based on the relative rates and costs of the subgroups, this study calculated the global cost (expected perioperative cost of surgery plus complication cost) to be
5. Conclucsion Patients younger than three years of age are more likely to return to ED for dehydration. This is most significant for children under 2 years of age. PTH is more common in older children. Knowledge of the more likely complications for children of different ages may provide important information in anticipatory counseling and perioperative guidance for the physician, nursing and the patient's family. Future studies should aim to evaluate global costs related to post-operative returns to the ED and readmission rates in younger children undergoing T&A. Also, more studies should be performed to evaluate techniques of T&A surgery that may decrease overall risk of ED return visits. The 3
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109668
N.R. Lindquist, et al.
Fig. 3. The frequency of ED visits by different age bracket. Statistical test was performed using ANOVA with multiple comparison using Benjamini, Krieger and Yekutieli adjustments. Statistical significance was established at p < 0.05. * = p < 0.05, ** = p < 0.01. A) overall return, B) dehydration, C) bleeding, D) pain, E) emesis, F) respiratory distress, G) other, and H) fever.
Funding
intracapsular technique has shown to have a lower incidence of postoperative hemorrhage and pain and faster return to normal oral intake as compared with traditional electro-dissection tonsillectomy. This could be one of the tools in our armamentarium to drive down global costs related to T&A in the younger children by decreasing post-operative return ED visits.
The authors have no funding, financial relationships, or conflicts of interest to disclose. References [1] K.A. Cullen, M.J. Hall, A. Golosinskiy, Ambulatory surgery in the United States, 2006, Natl Heal Stat Rep 11 (2009) 1–25 https://www.ncbi.nlm.nih.gov/pubmed/ 19294964.
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[9] S. Mahant, R. Keren, R. Localio, et al., Variation in quality of tonsillectomy perioperative care and revisit rates in children's hospitals, Pediatrics 133 (2) (2014) 280–288, https://doi.org/10.1542/peds.2013-1884. [10] J.L. Curtis, D.B. Harvey, S. Willie, et al., Causes and costs for ED visits after pediatric adenotonsillectomy, Otolaryngol. Head Neck Surg. 152 (4) (2015) 691–696, https://doi.org/10.1177/0194599815572123. [11] A. Tomkinson, W. Harrison, D. Owens, S. Harris, V. McClure, M. Temple, Risk factors for postoperative hemorrhage following tonsillectomy, The Laryngoscope 121 (2) (2011) 279–288, https://doi.org/10.1002/lary.21242. [12] D. Myssiorek, A. Alvi, Post-tonsillectomy hemorrhage: an assessment of risk factors, Int. J. Pediatr. Otorhinolaryngol. 37 (1) (1996) 35–43 http://www.ncbi.nlm.nih. gov/pubmed/8884405 , Accessed date: 30 April 2019. [13] D.J. Doyle, E.H. Garmon, American Society of Anesthesiologists Classification, ASA Class, 2018. [14] J. Walton, Y. Ebner, M.G. Stewart, M.M. April, Systematic review of randomized controlled trials comparing intracapsular tonsillectomy with total tonsillectomy in a pediatric population, Arch Otolaryngol Neck Surg 138 (3) (2012) 243, https://doi. org/10.1001/archoto.2012.16. [15] K.W. Chang, Intracapsular versus subcapsular coblation tonsillectomy, Otolaryngol Neck Surg 138 (2) (2008) 153–157, https://doi.org/10.1016/j.otohns.2007.11.006. [16] Y.L. Wilson, D.M. Merer, A.L. Moscatello, Comparison of three common tonsillectomy techniques: a prospective randomized, double-blinded clinical study, The Laryngoscope 119 (1) (2009) 162–170, https://doi.org/10.1002/lary.20024.
[2] M.J. Hall, A. Schwartzman, J. Zhang, X. Liu, Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010, Natl Heal Stat Rep 102 (2017) 1–15 https://www.ncbi.nlm.nih.gov/pubmed/28256998. [3] L.B. Johnson, R.G. Elluru, C.M. Myer 3rd, Complications of adenotonsillectomy, The Laryngoscope 112 (8 Pt 2 Suppl 100) (2002) 35–36, https://doi.org/10.1002/ lary.5541121413. [4] R.B. Mitchell, S.M. Archer, S.L. Ishman, et al., Clinical practice guideline: tonsillectomy in children (update), Otolaryngol. Head Neck Surg. 160 (1_suppl) (2019) S1–S42, https://doi.org/10.1177/0194599818801757. [5] M.T. Brigger, S.E. Brietzke, Outpatient tonsillectomy in children: a systematic review, Otolaryngol. Head Neck Surg. 135 (1) (2006) 1–7, https://doi.org/10.1016/j. otohns.2006.02.036. [6] C.M. Lawlor, C.A. Riley, J.M. Carter, K.H. Rodriguez, Association between age and weight as risk factors for complication after tonsillectomy in healthy children, JAMA Otolaryngol Head Neck Surg 144 (5) (2018) 399–405, https://doi.org/10. 1001/jamaoto.2017.3431. [7] S.S. Goyal, R. Shah, D.W. Roberson, M.L. Schwartz, Variation in post-adenotonsillectomy admission practices in 24 pediatric hospitals, The Laryngoscope (10) (2013) 123, https://doi.org/10.1002/lary.24172 n/a-n/a. [8] J. Belyea, Y. Chang, M.H. Rigby, G. Corsten, P. Hong, Post-tonsillectomy complications in children less than three years of age: a case-control study, Int. J. Pediatr. Otorhinolaryngol. 78 (5) (2014) 871–874, https://doi.org/10.1016/j.ijporl.2014. 02.029.
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Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Age-related causes of emergency department visits after pediatric adenotonsillectomy at a tertiary pediatric referral center
T
Nathan R. Lindquista, Zipei Fenga, Ankita Patrob, Shraddha S. Mukerjic,∗ a
Department of Otolaryngology, Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA Vanderbilt Department of Otolaryngology, Nashville, TN, USA c Texas Children's Hospital, Department of Otolaryngology, Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Tonsillectomy Adenotonsillectomy Young Complications Age Revisits
Introduction: The complications of tonsillectomy and adenoidectomy (T&A) are well-described and include bleeding, dehydration, nausea, respiratory complications, and pain. After the immediate postoperative phase, the overall 30-day emergency department (ED) return rate is as high as 13.3%. However, few studies have examined the types and rates of late post-operative complications for children undergoing T&A stratified base on patient age. Herein, we aim to better characterize ED return visits for children of all ages, with special attention to those patients under three years of age. Methods: This is a retrospective case series at a tertiary academic pediatric medical center. All patients 18 years of age or younger who underwent T&A over eighteen months were included. Data including ED return diagnosis, post-operative day of presentation, and need for surgical intervention was recorded for patients who presented to the ED within 30 days of their original surgery. Results: 5,225 patients were identified, with an overall late complication rate of 12.8%. There was no difference in the 30-day ED readmission rate for children under the age of three, although children under the age of two were more likely to present to the ED. There was a significantly higher risk of dehydration for children under the age of four years, and a significantly higher bleeding risk and need for reoperation for control of post-tonsillectomy hemorrhage (PTH) for children over the age of six. Conclusions: The overall ED visit rate in this study is 12.8%, with no difference based on age. Patients younger than three years of age are more likely to return to ED for dehydration, while bleeding and need for control of oropharyngeal hemorrhage is more common in older children. Knowledge of the age-related late complications of T&A may direct appropriate anticipatory peri-operative counseling of risks and return precautions.
1. Introduction Tonsillectomy and adenoidectomy (T&A) is the second most performed ambulatory surgery for children in the United States [1,2]. The post-operative complications of tonsillectomy are well-described and include primary and secondary bleeding, as well as nausea, emesis, pain, dehydration, and respiratory issues such as post-obstructive pulmonary edema [3]. Late complication after T&A is defined as any complication occurring 24–48 h after surgery. Due to cited increased complications in children under the age of three, in children with other risk factors such as craniofacial disorders or Trisomy 21, and in children with severe sleep apnea, the recently updated American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS) Clinical Practice Guidelines for Tonsillectomy in Children recommends overnight inpatient monitoring for these children [4]. Multiple studies ∗
support statistically significant higher airway or respiratory complication rates for children age three and under, within the first 24 h after surgery [5,6]. Although post-T&A admission rates vary across tertiarycare centers, we routinely admit children under 3 years of age for postoperative 23-h observation [7]. The most common late complications include secondary post-tonsillectomy hemorrhage (PTH) or dehydration [8]. A retrospective review of the Pediatric Health Information System Database calculated a median 30-day return rate of 7.8%, with individual institution rates varying from 3.0% to 12.6% [9]. However, a recent study by Curtis et al. estimates an overall emergency department (ED) return rate at 13.3% for late post-operative complications for all children who underwent T&A at their institution [10]. These authors estimate that these visits make the global cost of T&A approximately 10% more costly than the perioperative costs, and suggest improved pain regimens and
Corresponding author. Texas Children's Hospital - West Campus, 18200 Katy Freeway, Suite 540, Houston, TX, 77094, United States. E-mail address: [email protected] (S.S. Mukerji).
https://doi.org/10.1016/j.ijporl.2019.109668 Received 1 May 2019; Received in revised form 20 August 2019; Accepted 31 August 2019 Available online 04 September 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109668
N.R. Lindquist, et al.
effective patient-communication as tools to decrease ED return visits. The objective of the study is to characterize patients that returned to the ED within the first 30 days of their T&A with regards to age and reason for presentation. We aim to augment the information obtained in prior studies by further analyzing age-specific reasons for ED visits after T&A surgery in a large study population. We believe that this information will serve as an improved guide to the patient's families regarding their expectations of perioperative recovery.
Table 2 Total complication rates.
2. Materials and methods Our retrospective chart review study was approved by the Institutional Review Board. An electronic medical record query was performed for all children under the age of 18 years who underwent T& A at our institution from January 3, 2017 to July 3, 2018. The inclusion criteria for this group was broad. All patients undergoing T&A were included, even if they underwent additional procedures. In addition, we did not exclude children with comorbidities or additional diagnoses. Data including age, gender, date of admission, date of surgery, American Society of Anesthesiologists (ASA) Score, and length of surgery were collected. Information including return diagnosis, post-operative day of presentation, and need for surgical intervention was obtained for patients who presented to the ED within 30 days of their original surgery. Patient reasons for ED visit or hospital readmission were sorted categorically into dehydration, bleeding, pain, nausea/ emesis, respiratory problems, fever, and others. For those patients requiring additional surgical intervention, Current Procedural Terminology (CPT) codes were collected and utilized in calculating PTH rates. At our institution, children under the age of three and those with moderate to severe OSA are routinely observed overnight following T& A. The standardized T&A pain regimen includes scheduled ibuprofen every 6 h with acetaminophen given as needed for breakthrough pain. In addition, a post-operative oral steroid dose is offered, on an as needed basis, between post-operative days four to seven. Statistical analysis was performed using Prism and Microsoft Excel. Unpaired T test, linear regression and ANOVA were used where appropriate. Statistical significance was established at p < 0.05.
5225 (100%) 2478 (47.5%)
251 (4.8%) 260 (5.0%) 31 (0.6%) 30 (0.6%) 16 (0.3%) 64 (1.2%) 15 (0.3%) 667 (12.8)
Our study showed significant age-related differences in the primary indication for return ED visits after T&A surgery. These results are similar to a previous large-scale retrospective cohort studies of the Pediatric Health Information System Database [9]. We noted that children under the age of four years had a significantly higher risk of dehydration, this was most significant in children under 2 years of age. We believe that this may be due to poorer pain control related to resistance to taking oral pain medications, lower physiologic reserve for fluid losses, and a lower parental threshold for ED presentation in younger children. Post-tonsillectomy bleeding and operating room return rate for control of PTH was increased for children over the age of six years [9,11,12]. This is similar to other studies that show increased rates of PTH for older children. Many older children undergo T&A for recurrent streptococcal tonsillitis which is known to be associated with increased incidence of PTH [12]. Our study evaluated a large cohort of patients undergoing T&A within an 18-month period, including nearly 10% of patients under the age of three years. Among all 5,199 patients, the post-operative 30-day ED readmission rate was 12.8%. This figure is within the range of 6.3%–13.3%, as reported in the literature [8–10]. Interestingly, there was no statistically significant difference in overall rates between the groups of children older or younger than three years. Our results also showed that children under 3 years of age have a higher ASA score. The ASA classification assumes that age is unrelated to physical status, although in practice the extremely young and elderly are far less tolerable of anesthetics as compared to normal, healthy young adults [13]. Either consciously or subconsciously, the ASA
Table 1 Patient characteristics.
Patient number Female Age Age < 3 0-2 2-3 Age > 3 3-4 4-5 5-6 6-7 7-8 8-18
Dehydration Bleeding Pain Emesis Respiratory Problems Other Fever Overall complication rate
4. Discussion
Included in the study cohort were 5,225 patients under the age of 18 whom underwent T&A at our institution between the specified dates (Table 1). The median age for this group was six years, and 48% of all patients were female. Overall rate of complication was 12.8% based on 30-day return to the Emergency Center, with dehydration and bleeding the most common primary indications for return visits (Table 2). Patients were divided into two groups based on age: less than 3 years and more than or equal to 3 years. Patients below the age of three
Number (%)
5225 (100%)
accounted for 10% of the study population. Of those patients, 39% of patients were female. Pre-operative risk stratification demonstrated a significantly higher ASA score for children under the age of 3 (Fig. 1A, p < 0.0001). No significant difference was demonstrated in operative time between the two groups. (Fig. 1B, p = 0.8). Post-operative 30-day Emergency Department (ED) readmission rate was 12.8% overall, with no statistically significant difference between the two groups. (Fig. 1D, p = 0.9). However, categorization of patients based on intervals of one year under the age of eight demonstrated a higher rate of 30-day returns to the ED in patients under age of 2 (Fig. 3A, p < 0.03) (see Fig. 2). Further analysis based on individual primary diagnoses for ED visits indicated a significantly higher risk of dehydration for children under the age of four years (Fig. 3B, p < 0.03). The bleeding risk and OR return rate for control of PTH was increased for children over age of six years compared to less than 6 years (Fig. 3C, p < 0.0001). We did not observe a statistically significant difference in ED presentation for postoperative pain or emesis across the study cohort. (Fig. 3D and E, p > 0.05). No significant difference was observed in rate of respiratory problems, fever and other causes of ED visits (Fig. 3F,G,3H, p > 0.05). In addition to the discretely defined categories, other causes of presentation included asthma, cough, epistaxis, gastroenteritis and motor vehicle collision.
3. Results
Characteristics
Primary Complications (All Ages)
515 (10%) 78 (1.5%) 437 (8.3%) 4703 (90%) 645 (12.3%) 695 (13.3%) 701 (13.4%) 650 (12.4%) 477 (9.1%) 1542 (29.5%)
2
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109668
N.R. Lindquist, et al.
Fig. 1. General characteristics of the study population 1A) Increased ASA score in children under 3 years of age. 1B) Surgery time between the two groups. 1C) Increased length of hospitalization in children under 3 years of age. 1D) Percentage of patients returning to ED.
approximately 10% higher than the perioperative cost across all age groups based on an ED visit. Interventions to decrease the dehydration rate, improve pain control and lower the risk of post-tonsillectomy hemorrhage may include perioperative parent and patient counseling, as well as different techniques including intracapsular tonsillectomy (IT). There is strong evidence mounting for IT for sleep-disordered breathing, including more expedient resolution of pain, return to normal diet & activity, lower analgesic requirement, and a lower rate of secondary PTH [14–16]. Strengths of our study include a large study cohort and significant information on ED return rates following T&A categorized by age and reasons for ED visits. We acknowledge a few weaknesses as well. Our study was a retrospective in design and therefore has its inherent limitations. We completed this review in one hospital system, and therefore, our results may not be generalizable to hospital systems of differing sizes or regions. In addition, the patient population at a tertiary referral center is markedly different from those of community otolaryngology practices. It is likely that a higher proportion of medicallycomplex and/or younger children undergo tonsillectomy at our institution. However, our hospital system has several community-based health centers that usually attract otherwise healthy children needing T &A surgery so our results should be generalizable to a large extent. With regards to return visits, it is possible that patients presented to other institutions for post-operative issues due to locality or preference and are thus underrepresented in our follow-up cohort. We also did not evaluate the effect of existing co-morbid conditions to ED return visits.
Fig. 2. Frequency of ED visits by diagnosis for the two study groups. Statistical testing was performed using unpaired parametric test, significance was established at p < 0.05. * = p < 0.05, ** = p < 0.01. DH (dehydration), BL (Bleeding), PA (Pain), EM (Emesis), RD (Respiratory distress), OT (Other), FE (Fever).
grading of increasingly younger children undergoing T&A may be biased by these assumptions. Recently, Curtis et al. examined the cost and etiologies for postoperative ED visits in patients undergoing T&A of all ages [10]. In their study, 13.3% of patients (n = 437) presented to the ED at a mean of 4.4 post-operative days and were included in the cohort. Similar to our data, 4.2% presented with dehydration, 3.3% for post-tonsillectomy hemorrhage, 2.0% for uncontrolled pain, 1.3% for fever, 1.0% for vomiting/nausea/GI discomfort, 0.7% for respiratory issues, and 1.2% for other causes. The subgroups in their analysis with the highest mean cost of readmission were those patients with respiratory complications ($2855), hemorrhage ($1502), and dehydration ($1372), while uncontrolled pain was the least expensive ($781). Based on the relative rates and costs of the subgroups, this study calculated the global cost (expected perioperative cost of surgery plus complication cost) to be
5. Conclucsion Patients younger than three years of age are more likely to return to ED for dehydration. This is most significant for children under 2 years of age. PTH is more common in older children. Knowledge of the more likely complications for children of different ages may provide important information in anticipatory counseling and perioperative guidance for the physician, nursing and the patient's family. Future studies should aim to evaluate global costs related to post-operative returns to the ED and readmission rates in younger children undergoing T&A. Also, more studies should be performed to evaluate techniques of T&A surgery that may decrease overall risk of ED return visits. The 3
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109668
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Fig. 3. The frequency of ED visits by different age bracket. Statistical test was performed using ANOVA with multiple comparison using Benjamini, Krieger and Yekutieli adjustments. Statistical significance was established at p < 0.05. * = p < 0.05, ** = p < 0.01. A) overall return, B) dehydration, C) bleeding, D) pain, E) emesis, F) respiratory distress, G) other, and H) fever.
Funding
intracapsular technique has shown to have a lower incidence of postoperative hemorrhage and pain and faster return to normal oral intake as compared with traditional electro-dissection tonsillectomy. This could be one of the tools in our armamentarium to drive down global costs related to T&A in the younger children by decreasing post-operative return ED visits.
The authors have no funding, financial relationships, or conflicts of interest to disclose. References [1] K.A. Cullen, M.J. Hall, A. Golosinskiy, Ambulatory surgery in the United States, 2006, Natl Heal Stat Rep 11 (2009) 1–25 https://www.ncbi.nlm.nih.gov/pubmed/ 19294964.
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